Provider Demographics
NPI:1376824797
Name:LATHAM, JEWELLYN DAVIN (OTR)
Entity Type:Individual
Prefix:
First Name:JEWELLYN
Middle Name:DAVIN
Last Name:LATHAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CUSTER ROAD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080
Mailing Address - Country:US
Mailing Address - Phone:972-490-9055
Mailing Address - Fax:972-265-0392
Practice Address - Street 1:2625 ANITA DR.
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041
Practice Address - Country:US
Practice Address - Phone:972-490-9055
Practice Address - Fax:972-265-0392
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111120225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics